Ann Thorac Surg 2005;80:2384-2386
© 2005 The Society of Thoracic Surgeons
How to do it
A New Technique of Subcutaneous Colon Interposition
Michael S. Kent, MD
a
,
Lloyd Gayle, MD
b
,
Lloyd Hoffman, MD
b
,
Nasser K. Altorki, MD
a
,
*
a Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York
b Division of Plastic Surgery, Department of Surgery, Weill Medical College of Cornell University, New York, New York
Accepted for publication June 11, 2004.
* Address correspondence to Dr Altorki, Department of Cardiothoracic Surgery, Suite M404, Weill Medical College of Cornell University, New York, NY10021 (Email: nkaltork{at}mail.med.cornell.edu).
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Abstract
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A colon interposition graft may be placed in the subcutaneous position when other routes are not available. Creation of an adequate subcutaneous tunnel may be difficult, especially in patients with prior sternotomy. In this report we describe a method that utilizes tissue expanders to facilitate subcutaneous esophageal reconstruction.
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Introduction
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The use of colon interposition for esophageal reconstruction is well established, particularly for benign disease [1–3]. The colon may be placed in the posterior mediastinum, behind the sternum, or in a subcutaneous tunnel. The subcutaneous route is rarely utilized because of its poor cosmetic appearance. Occasionally the conduit cannot be placed in either the esophageal bed or in the retrosternal position (eg, as after prior esophagectomy or open heart surgery). In these circumstances, subcutaneous placement of the esophageal substitute is one of the few remaining options. However creation of the subcutaneous tunnel can be challenging, especially after a prior sternotomy. The skin is firmly attached to the sternum and creation of adequate space for the conduit can be difficult. Furthermore, extensive dissection can easily lead to ischemia and necrosis of the overlying skin.
Tissue expansion is a technique whereby normal skin is stretched by placing a balloon in a subcutaneous or submuscular pocket. The expander is gradually inflated with the injection of saline over a period of weeks. The overlying skin remains viable and the space created is ideally suited for the passage of a conduit.
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Technique
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Two patients in whom a subcutaneous chest wall tunnel was easily created by the use of tissue expanders are presented.
Patient 1
This patient suffered an esophageal perforation from transesophageal echocardiography performed during coronary artery bypass grafting. He underwent several primary repair attempts at an outside institution without success. An esophageal stent was placed at the local hospital, and his sepsis resolved over a period of several weeks. However, he subsequently developed a tracheoesophageal fistula secondary to stent erosion, and he was referred to our institution for further management. The stent was extracted and an esophagectomy and cervical esophagostomy were performed through a right thoracotomy. The membranous trachea was repaired using a patch of autologous pericardium, and gastrointestinal reconstruction was deferred.
Given the extensive inflammation within the posterior mediastinum and the presence of coronary grafts in the anterior mediastinum, the only available position for a colonic interposition was subcutaneous. Given the prior median sternotomy, concern surrounded the adequacy of a subcutaneous tunnel. Thus the decision was made to prepare the space using two saline tissue expanders (Fig 1) (Versafil Tissue Expanders, Flowmatrix Corp, Carpinteria, CA). The proximal and distal segments of the previous sternotomy incisions were opened 5 cm. A right pre-pectoral plane of dissection was established from the clavicle to the costal margin, which extended 8 cm in width. Two tissue expanders of rectangular design were placed within the pockets. Remote ports were used, similarly placed in subcutaneous pockets of 2.5 cm diameter in the contralateral left pre-pectoral space. Initially, 25 mL of normal saline was instilled in each expander. Weekly expansion through the ports was performed for 6 weeks until each expander contained approximately 450 mL. This provided an adequate tunnel with well-vascularized soft tissue coverage to accommodate the proposed colonic interposition (Figs 2 and 3).
The tissue expanders were then removed, and an isoperistaltic colonic interposition graft to the cervical esophagus was created. Postoperatively an anastomotic leak developed in the patient, which was successfully treated by draining the cervical wound.
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Fig 2. Placement of the subcutaneous tissue expanders through the proximal and distal segments of the previous median sternotomy incision.
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Fig 3. Sagittal view of the subcutaneous tunnel. (Left) The sternum and pectoralis muscle are depicted. (Middle) The tissue expanders have been placed in the pre-pectoral plane. (Right) The tissue expanders have been removed and the subcutaneous colon interposition has been created.
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Patient 2
This patient also suffered an esophageal perforation in the setting of coronary artery bypass grafting. Abdominal tenderness and signs of sepsis developed several days after the procedure. The abdomen was explored with a presumptive diagnosis of a perforated ulcer. At laparotomy, a large perforation was noted in the distal third of the esophagus with an abscess cavity in the lesser sac. The distal esophagus was entirely necrotic and a transhiatal esophagectomy and cervical esophagostomy were performed. Gastrointestinal reconstruction was delayed. In anticipation of definitive reconstruction, saline tissue expanders were placed in the subcutaneous space several months later and were gradually expanded. An isoperistaltic left colonic interposition graft was later performed, which was followed by an uneventful recovery.
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Comment
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Placement of the colonic graft in the subcutaneous position is quite uncommon. Interestingly, the first 3 reported cases of colon interposition by Kelling (1911), Lunblad (1921), and Roith (1924) all described subcutaneous placement [4]. However, due to poor cosmetic appearance, this technique has been largely abandoned. In a recent series of 255 patients who underwent esophagectomy and reconstruction for benign disease, the conduit was placed subcutaneously in only 7 (3%) [5]. Nonetheless, occasionally the subcutaneous position may be the only route available. Both patients described in this report suffered esophageal perforation in the context of coronary artery bypass grafting, and thus the anterior mediastinum was not available for placement of the conduit. Furthermore, obliteration of the esophageal bed after previous esophagectomy precluded using the posterior mediastinum. Placement of the esophageal substitute in the subcutaneous position is the only available option in such instances. However, the scarring associated with a previous midline skin incision or mediastinal radiation may preclude the creation of an adequate subcutaneous tunnel. A tight tunnel may easily impede venous drainage and threaten the viability of the graft.
The use of tissue expanders in both cases allowed reconstruction to be safely and expeditiously carried out. Slow expansion of the subcutaneous space over a period of several weeks permitted the colon to be placed without tension and avoided the risk of ischemic necrosis of the overlying skin. In addition, the capsule that forms around the tissue expander creates a gliding surface that serves as an interface between the conduit and the subcutaneous space. Tissue expanders have found limited application in cardiothoracic surgery, such as management of sternal wound infections [6] and postpneumonectomy syndrome [7, 8]. We believe that this represents the first report of tissue expanders to facilitate placement of subcutaneous colon interposition grafts.
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References
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- Wain J, Wright C, Kuo E, et al. Long segment colon interposition for acquired esophageal disease Ann Thorac Surg 1999;67:313-318.[Abstract/Free Full Text]
- Mansour K, Bryan C, Carlson G. Bowel interposition for esophageal replacement25 year experience. Ann Thorac Surg 1997;64:752-756.[Abstract/Free Full Text]
- Cerfolio R, Allen M, Deschamps C, Trastek V, Pairolero P. Esophageal replacement by colon interposition Ann Thorac Surg 1995;59:1382-1384.[Abstract/Free Full Text]
- May I, Samson P. Collective reviewesophageal reconstruction and replacements. Ann Thorac Surg 1969;7:249-277.[Medline]
- Young M, Deschamps C, Trastek M, et al. Esophageal reconstruction for benign diseaseearly morbidity, mortality and functional results. Ann Thorac Surg 2000;70:1651-1655.[Abstract/Free Full Text]
- Hauben D, Shulman O, Levi Y, et al. Use of the SpaceMaker balloon in sternal wound closurecomparison with other techniques. Plast Recon Surg 2001;108:1582-1590.
- Downey R, Trastek V, Clay R. Right pneumonectomy syndromesurgical correction with expandable implants. J Thorac Cardiovasc Surg 1994;107:953-955.[Free Full Text]
- Tsunezuka Y, Sato H, Watanabe S, et al. Improved expandable prosthesis in postpneumonectomy syndrome with deformed thorax J Thorac Cardiovasc Surg 1998;116:526-528.[Free Full Text]
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Abstract
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